Last fall The Joint Commission (TJC) published sentinel event data from 2004 through the first 3 quarters of 2011.1 While TJC cautions that this data is not epidemiologically meaningful because the events are for the most part voluntarily self-reported and represent only a small portion of actual events, TJC encourages us to recognize that information from these reports and resulting root cause analyses are an important source of information for “lessons learned” that can help prevent similar adverse events from occurring.
During the first 3 quarters of last year, TJC reviewed 14 transfusion-related sentinel events taking the total to 92 investigated “hemolytic transfusion reactions involving administration of blood or blood products having major blood group incompatibilities” since 2004. What lessons are these events teaching us?
In 1999, TJC reported2 that the causes of transfusion sentinel events most commonly fell into six general categories: care planning, information-related (patient identification and labeling), staff training and sufficiency, communication, patient assessment, and product storage outside blood bank.
In the 2011 report, leadership is identified as the most frequent cause of mistransfusions, with leadership being defined to include standardization (e.g. guidelines, (aka planning)), culture, resource allocation and policies. Other common root causes continue to be information management, staff training and sufficiency, communication, patient assessment and physical environment.
Although definitions have been refined, some terminology has changed, and leadership is now being recognized as an independent cause of sentinel events at the bedside, the healthcare community still has lessons to learn when it comes to improving blood transfusion safety. The causes of the 2011 transfusion-related adverse events appear to be very much the same as the root causes identified in the Sentinel Event Alert that TJC published in 1999.2
A comprehensive, evidence-based blood management program addresses each of the root causes of transfusion related sentinel events: Physicians who order blood products must receive formal training in blood management and implement standardized transfusion guidelines based upon current scientific evidence.3,4,5 Similarly, nurses need continuous formal training in transfusion safety and blood administration competency.6 Finally, effective blood utilization oversight is required to assure appropriate care planning for patients at risk of significant blood loss, the safest possible resource allocation, and transfusion guidelines based upon best practice. Until hospitals embrace a meaningful blood management program, patients will continue to be at risk for unnecessary blood product administration and transfusion-related sentinel events. The lesson, as always, is to apply current evidence to improve the quality of care and patient safety.
- Sentinel Event Alert No. 10, , The Joint Commission, Aug. 30, 1999.
- Dzik WH. Emily Cooley Lecture 2002: transfusion safety in the hospital. Transfusion 2003; 43:1190-9.
- Stover EP, Siegel LC, Parks R et al. Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study. Institutions of the Multicenter Study of Perioperative Ischemia Research Group. Anesthesiology 1998;88:327-33.
- Corwin HL, Gettinger A, Pearl RG et al. The CRIT Study: Anemia and blood transfusion in the critically ill–current clinical practice in the United States. Crit Care Med 2004;32:39-52.
- Boucher BA, Hannon TJ. Blood management: a primer for clinicians. Pharmacotherapy 2007;27:1394-411.